eMedicine Specialties > Allergy and Immunology > Allergy Pathogenesis
Indoor Aeroallergens
Updated: Dec 3, 2008
Introduction
John Bostock first described hay fever in 1819, but not until 1873 did Charles Blackley recognize that pollens cause this disease. In 1921, Kern noted that a patient with asthma had a positive prick-puncture skin test result to extracts obtained from her mattress.1 The patient's asthma improved after she enclosed the mattress in heavy packing paper and thoroughly cleaned the room. In 1925, Storm van Leeuwen successfully treated patients with asthma by moving them to high altitudes or enclosing them in an allergen-proof chamber.2
Despite the early recognition that environmental exposure to allergens causes allergic diseases, indoor allergen avoidance is still an underused treatment. Even when properly prescribed by physicians, the benefits of indoor allergen avoidance are often decreased by inadequate patient compliance. Atopic diseases, which affect up to 30% of the population in some countries, are an increasing problem, particularly in developed countries. Allergic diseases and asthma also cause substantial morbidity and mortality, which significantly affects the quality of life of those who have these disorders. Half of all adults with asthma and 80% of children with asthma have an allergic component to their disease. Asthma is the most common chronic disease in childhood and accounts for up to 250,000 deaths per year worldwide.
Both outdoor and indoor aeroallergens sensitize and exacerbate allergic asthma and rhinoconjunctivitis. Major outdoor allergens include those derived from the pollens of trees, grasses, and weeds. Major indoor allergens are derived from dust mites, molds, cockroaches, cat, dog, and other furry animal debris. Allergens are located both in homes and in other indoor environments. For example, one study found that most daycare facilities sampled had detectable levels of major indoor allergens; many contained levels sufficient to cause sensitization and exacerbation of allergic diseases.3
The physician has 3 treatment options for patients with allergic diseases, including allergic asthma. These include aeroallergen avoidance, medications to control symptoms, and allergen immunotherapy. In developed countries, more than 90% of the average person's time is spent indoors. This statistic underscores the importance of avoidance measures, especially in patients who are allergic to indoor allergens.
Major Indoor Allergens
Dust mites
Dust mite debris is the major source of allergens in house dust.4,5 These microscopic arthropods primarily feed on human skin scales. They lack an organized respiratory system, their water supply is derived from the ambient air, and acaricides are not effective to control their presence and numbers. Seasonal changes in relative humidity can affect the concentrations of dust mite allergen, and these fluctuations can contribute to allergic symptoms in the sensitized individual (see Media file 1).6
In the home, mites typically infest objects that contain fabrics; for example, higher concentrations of mites are found in mattresses, pillows, bedding, carpets, throw rugs, stuffed animals, and upholstered furniture. Higher concentrations are usually found in older homes, in regions of high humidity, and in homes with heating units other than forced air.7 Cold dry air at high altitudes is not conducive to dust mite growth.
Both the mite bodies and fecal pellets are major sources of mite allergens, which become airborne when disturbed.5 Dust mite allergens are predominately contained on aerodynamic particles 10 µm or larger in diameter and remain in the air for 30 minutes or less. In contrast, cat allergens are predominately carried on smaller particles, with an average size of 5 µm, and can remain in undisturbed air for days.
Allergens are named according to the first 3 letters of the genus and the first letter of the species (eg, the allergen for Dermatophagoides pteronyssinus is classified as Der p and Dermatophagoides farinae is classified as Der f). Allergens are grouped according to biologic function and homology. The major sources of dust mite allergens are the group 1 allergens Der p 1 and Der f 1.
The concentration of dust mite allergens (an indirect assessment of exposure) is measured in micrograms per gram (mcg/g) of settled dust from samples obtained by vacuuming a defined area of a carpet or mattress. The proposed threshold concentration of allergenic exposure required to sensitize to dust mites is 2 mcg of group 1 allergen (Der p 1 and Der f 1) per gram of dust. levels of 10 mcg/g of dust induce allergic symptoms or asthma in sensitized persons, but lower levels may also cause symptoms in these individuals.
Evidence that sensitization may occur at even lower levels also exists; hence, an individual genetically predisposed to develop allergic diseases may not have a safe level of exposure. More than 80% of homes in the United States and 85% of daycare facilities have detectable levels of dust mite allergens.7 Furthermore, half of US homes have levels higher than the proposed threshold levels for sensitization; about 25% have levels at or higher than those required to induce asthma.7
Cats and dogs
The 2 animals most commonly kept in US homes are cats and dogs; thus, these animals are major contributors to indoor allergen exposure. In a study reported in 2004, Arbes et al found that all homes in the United States (even those that have never had an animal in the house) contain dog allergen and virtually all contain detectable levels of cat allergen.8 Most of the homes sampled contained levels that exceed the proposed levels for both sensitization and exacerbation of asthma symptoms.
Felis domesticus (Fel d 1), the major cat allergen, is produced primarily in the sebaceous glands and is secreted onto the skin and fur.9 This allergen is also present in the salivary glands; thus, cats add additional allergen to their fur when they clean themselves. The production is evidently partially under hormonal control, since castration of male cats reduces levels of Fel d 1.9 The allergen is chiefly carried on small particles and remains airborne for long periods. Decreased ventilation in the home leads to increased levels of cat allergen. Increasingly airtight homes have potentially increased the exposure to cat allergens. Unlike dust mite allergens, cat allergens can be found even at high levels on walls and other surfaces within the home.10 The major dog allergens, Canis familiaris 1 (Can f 1) and Canis familiaris 2 (Can f 2), have physical properties similar to those of cat allergens.
The amount of exposure to an animal allergen necessary to cause sensitization is controversial. The proposed threshold level for sensitization by cat allergen is 1 mcg/g of dust, and the level to cause symptoms in susceptible individuals with asthma is 8 mcg/g of dust. For dog allergen, the proposed levels for sensitization and exacerbation are greater than 2 mcg/g of dust and greater than 10 mcg/g of dust, respectively; however, lower levels have been reported to be associated with sensitization. Observational studies suggest that high exposure to cat allergen early in life is associated with a decreased risk of cat allergy.11 However, an earlier study suggests that the opposite is true (see Table 1 below).12
Cockroaches
Of the roughly 3500 known species of cockroaches in the world, only 5 are important sources of indoor allergens. The 2 most commonly encountered species are the German (Blatella germanica) and the American (Periplaneta americana) cockroaches (see Media file 2; see Table 1 below). Cockroach allergens are derived from saliva, fecal material, secretions, and dead bodies of cockroaches. The airborne allergen particles from cockroaches are similar to dust mite aeroallergens in that they are relatively large (>10 µm in diameter). As such, they tend to become airborne after disturbance and then quickly fall to the ground. The proposed threshold levels of the major cockroach allergen B germanica (Bla g 1) required for sensitization and asthma symptoms are 2 units (U) per gram and 8 U/g, respectively.
An association between cockroach sensitization and more frequent episodes of asthma among patients in the emergency department has been described. Cockroach exposure among persons with asthma who reside in inner-city areas could account for the disproportionately high morbidity in this population, and the association of low socioeconomic status and cockroach allergy appears to be independent of age, sex, and race. Several studies have demonstrated that cockroach allergy is found not only in the inner city but also in any substandard housing conditions or where apartments are infested with cockroaches.
Fungi
Fungi, or molds, are widely distributed throughout the world. They grow in mycelium and reproduce asexually (by budding) and sexually (through spores). These spores then become airborne and have the potential to sensitize and cause symptoms in susceptible individuals. The optimal conditions for fungal growth vary greatly among different species, but all require oxygen, a carbohydrate source, and water. Optimal temperatures for fungal growth also vary but are usually between 18°C and 32°C.
Higher outdoor levels of fungi are associated with concomitant high levels in the indoor environment. Indeed, most of the fungi recovered from an indoor environment emanate from outside. However, certain species, such as Penicillium and Aspergillus, can be found in greater quantities inside buildings and homes. Another source of indoor fungi is the transport of outdoor spores into the indoor environment on clothing and animal fur (see Table 1 below).
Among children with allergies, 63% of their homes had increased fungal levels. More than one third of children with asthma who live in an inner city in the United States had a positive skin test result to Alternaria. Because asthma severity has been linked to sensitivity to Alternaria species, this finding may partially account for the unusually high morbidity due to asthma in this population.
The threshold levels of allergens that are required to sensitize and exacerbate allergic symptoms have yet to be established. Culture methods are usually used to determine exposure, using spore counts or quantitation of colony-forming units. Indoor spore levels higher than 1000/m3 of air or colony-forming units in the range of 1,000-10,000/m3 of air suggest indoor fungal contamination.
Table 1. Major Indoor AeroallergensOpen table in new window
Table
| Common Name | Scientific Name(s) | Area(s) of High Concentration | Source of Allergen |
| Dust mite | Dermatophagoides pteronyssinus (Der p 1), Dermatophagoides farinae (Der f 1) | Bedding Upholstered furniture Carpeting | Mite body Mite feces |
| Cat, dog | Felis domesticus (Fel d 1), Canis familiaris (Can f 1) | Bedding Upholstered furniture Carpeting | Sebaceous glands Salivary glands |
| Cockroach | Blattella germanica (Bla g 1), Periplaneta americana (Per a 1) | Kitchen | Saliva Fecal material Secretions Dead cockroach bodies |
| Fungi | Alternaria alternata (Alt a 1), Cladosporium herbarium (Cla h 1), Aspergillus fumigatus (Asp f 1) | Variable | Spores |
| Common Name | Scientific Name(s) | Area(s) of High Concentration | Source of Allergen |
| Dust mite | Dermatophagoides pteronyssinus (Der p 1), Dermatophagoides farinae (Der f 1) | Bedding Upholstered furniture Carpeting | Mite body Mite feces |
| Cat, dog | Felis domesticus (Fel d 1), Canis familiaris (Can f 1) | Bedding Upholstered furniture Carpeting | Sebaceous glands Salivary glands |
| Cockroach | Blattella germanica (Bla g 1), Periplaneta americana (Per a 1) | Kitchen | Saliva Fecal material Secretions Dead cockroach bodies |
| Fungi | Alternaria alternata (Alt a 1), Cladosporium herbarium (Cla h 1), Aspergillus fumigatus (Asp f 1) | Variable | Spores |
Avoidance Measures and Interventions
Indoor allergens can be avoided with 2 primary measures. First, the patient can be moved away from the allergen; second, the patient's home environment can be modified to reduce allergen exposure. The latter strategy is usually more practical in clinical practice.
Controversy exists over the effectiveness of individual environmental control strategies, but a comprehensive approach to allergen avoidance is superior to a single intervention.13 Conflicting results among studies that address primary prevention of atopic disorders have failed to lead to a consensus for recommendations to parents who wish to decrease the risk of atopy in their offspring.
The recommendations for allergen avoidance cannot be uniform for all patients. A comprehensive strategy should include determining the allergens to which the patient is sensitive and implementing specific avoidance measures to reduce exposure to the offending allergens. Furthermore, no avoidance strategy is complete without a thorough discussion with the patient, the patient's family, or both regarding the role of allergens in the disease. The success of such a strategy depends on the physician's attitude as to the effectiveness of avoidance measures, patient motivation and means to apply this strategy, exposure to allergens outside the patient's home, and the correct identification of all relevant allergens.
Table 2. General Recommendations for Aeroallergen Avoidance
Open table in new window
Table
| Major Allergen | Avoidance Strategies |
| Dust mite | Impermeable (woven) covers (pillows, mattresses) Elimination of dust reservoir (carpets, upholstered furniture) Weekly vacuuming Weekly washing of bedding in hot water Reducing indoor humidity |
| Cat, dog | Pet removal Pet washing Impermeable covers High-efficiency particulate air (HEPA) filters |
| Cockroach | Pesticides Thorough cleaning Elimination of food and water supply |
| Fungi | Closing windows and doors Repairing all leaks Using air conditioning Heating all rooms in the winter Removal of contaminated source Cleaning contaminated area with bleach solution |
| Major Allergen | Avoidance Strategies |
| Dust mite | Impermeable (woven) covers (pillows, mattresses) Elimination of dust reservoir (carpets, upholstered furniture) Weekly vacuuming Weekly washing of bedding in hot water Reducing indoor humidity |
| Cat, dog | Pet removal Pet washing Impermeable covers High-efficiency particulate air (HEPA) filters |
| Cockroach | Pesticides Thorough cleaning Elimination of food and water supply |
| Fungi | Closing windows and doors Repairing all leaks Using air conditioning Heating all rooms in the winter Removal of contaminated source Cleaning contaminated area with bleach solution |
Dust Mites
Impermeable covers
Several studies show that using impermeable mattress covers is not an effective strategy by itself to reduce the symptoms of allergic rhinitis or asthma.13,14 However, a study by Morgan et al demonstrates significant benefit of impermeable covers when used as part of a comprehensive and individualized allergen avoidance program.15 Impermeable covers are composed of either vinyl or tightly woven fabric and serve as effective dust mite barriers. Because vinyl is impermeable to air, it tends to be hotter and less comfortable than a woven cover, which is more comfortable but, usually, more expensive. In addition, nonwoven mattress encasements have been shown to accumulate mite allergen, in contrast to woven encasements.16 In either case, the covers used should encase the pillows, mattress, and box spring. These coverings may be purchased from retail stores, Web sites, mail-order catalogs, and allergy specialty stores (eg, www.allergysolution.com).
Elimination of dust reservoirs
The removal of dust reservoirs remains an important part of the avoidance program, although it can be difficult and expensive. Removal of carpets, draperies, and upholstered furniture decreases mite exposure. The patient should also remove stuffed toys, books, or other items that collect dust, particularly in the bedroom.
Vacuuming
Weekly vacuuming is recommended, and vacuum bags should have 2 layers or a HEPA filter to decrease aerosolized allergen exposure due to the air disturbance. Patients allergic to dust mites should try to avoid vacuuming or being present when the bag is changed. The use of a pollen mask (eg, Nexcare All Purpose Mask [3M, St Paul, Minn]) can also be helpful if patients are unable to avoid vacuuming.
Dehumidifiers
Because dust mites depend on a humid environment to live, reducing the relative humidity level to less than 50% can be helpful. However, a level of relative humidity low enough to effectively restrict mite population growth is difficult to maintain in most locales. Dehumidifiers are expensive and are not very effective, particularly in areas that have a high humidity level all year. Bedroom dehumidifiers are not effective and are not recommended for routine use.
Washing
Washing linens in hot water (55°C [130°F]) at least weekly is recommended to kill the mites and remove most of the associated allergen.
Air purifiers
Because dust mite allergens do not remain airborne for long periods, air purifiers alone are not very useful for dust mite allergen control. The routine use of air purifiers is not recommended because clinical benefits are not documented.
Freezing
Dust mites die when frozen; therefore, stuffed toys and other such items can be placed in a domestic freezer to decrease dust reservoirs. In climates where the outside temperature drops below freezing, rugs, blankets, mattresses, or other items may be placed outside for 2-3 days to kill dust mites.
Acaricides
Controlled studies on the effects of chemicals in controlling dust mite populations have yielded mixed results. Disodium octaborate tetrahydrate (DOT) is safe for humans and effectively kills mites. In one study, a single application of DOT, in combination with vacuuming, effectively reduced both mite population and mite allergen levels.
Duct cleaning
Because dust mites do not typically reside in air ducts, cleaning air ducts is not likely to decrease dust mite exposure.
Relocation
Although not usually very practical, moving to locations that are less favorable for dust mite growth is beneficial. For example, high altitudes or arid locales are associated with less mite growth.
Cats and Dogs
Removal of the pet
One of the most important recommendations for the patient may also be the most difficult to accept, since some pets are considered to be a part of the family. However, patients must understand that continued exposure to a pet and its allergens occurs if a family keeps the pet in the home. Once the pet is removed, the time required for allergen levels to decrease to levels at which allergic problems no longer occur can be as long as 6 months.17
Restrict pet access
If the patient decides to keep the offending pet, the pet should be kept outdoors. A less desirable option is to keep the pet in one area of the home and out of the bedroom.
Washing the pet
The current recommendation for a dog owner who is allergic to his or her pet is to wash the pet at least twice weekly. This recommendation is based on a study that showed reduced levels of antigen recovered from the dog hair and dander following washing; however, antigen levels rapidly increase in 3-4 days.18 For a cat owner, the task of washing the pet is more difficult because cats are more resistant to washing. Studies that evaluated pet washings have yielded conflicting results; however, in all cases, the effects are transient.
Impermeable covers
Impermeable coverings are recommended for the mattress, box spring, and pillows.
High-efficiency air cleaner
Because animal allergens remain airborne much longer than dust mite allergens, air purifiers may be beneficial; however, data to support this premise are lacking.
Removal of carpeting and upholstered furniture
Elimination of the reservoirs for allergens is an important component of the avoidance strategy.
Vacuuming
A study on the effects of vacuuming on cat allergen levels in the home failed to show any beneficial effects even when modern HEPA filters were used. In fact, the amount of cat allergen found increased, possibly due to the sweeping motion of the brushes on the carpeting and the air disturbance from the exhaust flow.
Cockroaches
Pesticides
An important aspect of cockroach eradication is the proper use of effective pesticides. Because the kitchen is the main source of both food and water for these insects, this room contains the most roach allergen. Pesticide spray is effective, but selective placement of gels or baits is preferred. Potential targets should include any cracks or other points of entry throughout the house.
Cleaning
Before pesticide application, a thorough cleaning is recommended so that the cockroaches are more likely to feed on the gel or bait. All surfaces with potential contact with the insect should be cleaned to reduce allergen levels. Particular attention should be paid to kitchen cabinets and the space around household appliances. The addition of liquid bleach facilitates removal of the allergens.
Elimination of food and water supply
Access to food and water should be eliminated to effectively eliminate cockroaches from the home. Food should be stored in sealed containers, and any sources of standing water should be removed. Routine chores such as washing the dishes and removing the trash from the home should be done daily. Food left out overnight promotes cockroach infestation.
Fungi
Reduce spore infiltration
Because most of the fungal spores detected in a home are derived from outdoors, windows and doors should be kept closed as much as possible.
Moisture control
Decrease the indoor humidity level to less than 50%, if possible. Repair leaks, use air conditioning at times of high humidity, ventilate bathrooms and kitchens, and heat all rooms in the winter.
Cleaning
A detergent solution with 5% bleach is useful for washable wallpaper and paneling. The disinfectant is prepared by adding 0.25-1.5 cups of bleach per gallon of water and a liquid detergent. Removal of the contaminated source may be necessary to reduce allergen exposure.
Air filters
HEPA filters are more effective than electrostatic air filters in removing fungal allergens from the air.
Masks
Activities such as cleaning and vacuuming can expose the individual to various fungal allergens; therefore, a pollen mask is useful in such situations.
Conclusion
Modern medicine has vastly increased the effective treatments of allergic disorders and asthma. However, the first line of treatment for these diseases is to avoid the offending agent. Therefore, the clinician should instruct patients who have allergies to indoor aeroallergens about practical matters to decrease exposure to these allergens. This is the most cost-effective treatment modality, and it sometimes results in complete resolution of an allergic problem when an individual is allergic to an indoor aeroallergen.
Asthma Resources from Medscape and eMedicine
Multimedia
 | Media file 1: Electron photomicrograph of Dermatophagoides farinae. |
 | Media file 2: Comparison of common cockroaches. |
Keywords
indoor aeroallergens, indoor environmental control, indoor allergens, prevention of indoor allergies, allergic rhinitis, asthma, asthma avoidance measures, allergy avoidance, dust mite allergy, cat allergy, dog allergy, fungus allergy, mold allergy, cockroach allergy, fungal allergy, HEPA, high-efficiency particulate air filter, indoor allergy, pet dander
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Further Reading
Keywords
indoor aeroallergens, indoor environmental control, indoor allergens, prevention of indoor allergies, allergic rhinitis, asthma, asthma avoidance measures, allergy avoidance, dust mite allergy, cat allergy, dog allergy, fungus allergy, mold allergy, cockroach allergy, fungal allergy, HEPA, high-efficiency particulate air filter, indoor allergy, pet dander
